Workplace Stress: Time to Think About It Now

Many people will be back to work today. Faced with an inordinately high in-tray or seemingly endless list of unread e-mails to be tackled urgently they will feel an immediate ramp up in stress levels after being able to take it easy for a couple of weeks. Of course a few others will feel relief at getting back to work after a stressful fortnight at home with the kids but the majority of people returning to work today will feel an increase in their stress levels as they get down to their days work.

Obviously there are many who never stopped working and workplace stress is a constant factor that never goes away.

The issues of workplace stress are well recorded as is the impact it has on sickness levels and general well-being yet we talk very little about workplace stress in front line social care. The Health and Safety Executive state the 40% of work related illnesses are stress related and that ‘human health & social work’ is one of the areas where the highest rates occur (http://www.hse.gov.uk/statistics/causdis/stress/index.htm)

Front line care workers, whether providing care in a person’s home or working in a care home are subject to stress in the work place as much as (if not more) to anyone sitting in an office, working in a shop or factory etc. Stress is not limited to the ‘big’ events in life, stress accumulates as the small things niggle away at us and without the opportunity to release that stress externally it eats away inside us causing physical illness that, eventually, can do significant damage to our health.

Imagine the pressure on a home care worker who has to do a number of 30 minute visits to vulnerable people. The time pressure to get their work done in that 30 minutes followed by the pressure of travelling to visit the next person who needs support and care, this can be made even more demanding if the worker never knows who they will be visiting that day or they have a workload that means they have even less time to travel between homes.

Working in a care home can be stressful too. Meeting the needs of those who depend on others for many aspects of their daily lives can take its toll on those responsible for delivering that support and care. Imagine dealing daily with incontinence, challenging behaviour and even death. The stress of working in a shop or office is mild in comparison.

And if that stress is not enough for the front line care worker there are also the issues of low pay and unsociable hours to contend with.

Where people have high levels of stress they react by either internalising it, which leads to health problems or they externalise it, usually by demonstrating aggressive behaviour. In front line social care both are dangerous.

Internalising stress can affect our concentration and, in front line social care, which can lead to dangerous errors, stress also impacts on our immune system making us more prone to any bugs or ailments floating around. In front line social care this can lead to spreading those germs to vulnerable adults whose immune systems are already weak. Given the nature of front line social care, with its culture of low pay and only paying statutory sick pay there is a reluctance for many care workers to take time off for illness unless they are physically unable to leave their house.

Externalising stress is even more dangerous in front line social care. It can lead to abusive behaviour.

Yet despite the acknowledgment that workplace stress has a real impact on peoples’ lives, in social care this is something rarely mentioned or acknowledged. For example, the Skills for Care Manager Induction Standards do not mention the need to monitor and address workplace stress (http://www.skillsforcare.org.uk/Document-library/Standards/Manager-Induction-Standards/Manager-Induction-Standards.pdf) and the Care Quality Commission Standards focus more on competency in their “Guidance about Compliance” on the standard of supporting workers rather than tackle the real issue of workplace stress and its potential to lead to failure to deliver safe services (http://www.cqc.org.uk/sites/default/files/media/documents/guidance_about_compliance_summary.pdf).

If we truly want the best services for the most vulnerable in society then we need to recognise the stress that can be placed on those delivering the actual services. Everyone deals with stress in different ways and, because of that, there needs to be a focus on managers and providers having good quality training and awareness of the issues associated with workplace stress and being able to demonstrate competency in dealing with workplace stress issues.

Social Value and Social Care

What did you want to be when you grew up?

Perhaps you wanted to be a train driver or a nurse, maybe you wanted to be a famous sports star or singer, or even, possibly, you wanted to be a princess or a pirate.

The chances are that the idea of being a social care worker did not enter your head.

Then as you got older and you discovered your talents and abilities your dreams will have changed, more professional ambitions may have come to mind, accountancy, medicine, architect, law etc. Perhaps, you were more vocationally minded, and liked the idea of a more hands on job, beauty therapist, mechanic, hairdresser, electrician etc.

The chances are that the idea of being a social care worker did not enter your head.

The fact that social care is well down the list of career choices is also backed up by the facts. The Skills for Care National Minimum Data Set (NMDS) shows that 60% of social care workers are aged 35 or over with just 10% under the age of 24. Social care is a job that people enter into later in life.

The issue with social care is how we value it in society and even though they provide essential front line services for vulnerable people, social care workers are low on social value.

Part of the issue is invisibility in society. Yes we have seemingly endless negative reporting, but generally speaking adult social care only becomes important to individuals when they, or a loved one, needs care services. In popular media social care is often portrayed negatively and infrequently, when fictional programmes portray social care as either inefficient or outright failing. Even where we have had mainstream fiction about care (i.e. Waiting for God) the care staff were not portrayed particularly well.

High social value needs positive role models through mainstream media and fiction often carries more weight than factual programmes. Fiction carries archetypes that embed themselves in social awareness (you’d be surprised how many people think the ‘medieval’ stories of King Arthur are true!) and in order to raise the social value of social care we need more positive archetypes of social care work portrayed through fiction.

That does not mean that non-fiction media doesn’t have a role to play. We increasingly need positive social care stories to underpin the social value of social care. Unfortunately the mainstream media seems adverse to the positive side of social care, which is strange as more and more of their viewers/readers will need social care services or know someone who needs social care services and the relaying of the negative horror stories and experiences, that are not suffered by the majority of care users, undermine the whole system. Yes it is important that these are exposed yet the overall impact has a detrimental effect and probably puts a lot of people off the idea of working in social care.

Social care is important in today’s (and tomorrow’s) society. Increasing longevity combined with a larger population means that social care services are needed more than ever before and more and more people are needed to provide that care. We need to raise the social value of social care, raise awareness in society of social cares importance in society and we need positive role models to encourage people to consider a career in social care.

The Challenges of Social Care Inspection

The appointment of Andrea Sutcliffe as Chief Inspector for Social Care at the Care Quality Commission is a highly commendable one. Not only is she knowledgeable about the care sector (see for example http://www.guardian.co.uk/social-care-network/2013/jul/15/what-good-homecare-looks-like) but she also has her own personal experiences to draw upon (http://www.whentheygetolder.co.uk/finding-care-for-older-relatives/) and that combination, along with her naturally open approach, bode well for the future inspection of social care.

Yet that future is strewn with challenges that Andrea first needs to tackle. The general perception of social care is not great and trust in the Regulators has been severely dented over recent weeks. The first challenge will be defining a model of inspection that will ensure poor provision is identified and stamped out yet this model must also reflect the nature of the care sector and the huge variations within it.

Yesterday, for example, the new Chief Inspector for Hospitals, Prof Sir Mike Richards, outlined a model which he frequently referred to as ‘an army’, 20 or more inspectors marching into a hospital to inspect all aspects of care provision and ensure the meeting of standards. Unfortunately, in social care that will not work as, in many instances that many inspectors would outnumber both residents and staff!

The variation in social care is completely different from that of hospitals. Social care covers care homes and home care, it covers care and support for the elderly and care and support for those with learning disabilities, it covers large care providers with 100’s of homes as well as micro providers with just a few beds. Finding a model of social care inspection that fully encompasses the variation while ensuring consistency is, in itself, a challenge.

The Care Quality Commission has recently stated that it intends to have more specialist inspectors and social care could really benefit from this approach. For example recent reports have highlighted training and development issues with Health and Social Care staff and having learning and development specialists as part of the inspection process can help raise awareness of the importance of staff development, encourage providers to focus on training and development and help identify failings where providers fail to implement staff training and development. Similarly specialists in infection control or nutrition could have a significant impact.

One thing that would be good to see, and may well happen given Andrea’s former job, is a focus on best practice information and its application both by providers and inspectors. Resources, for example, from the three main national bodies, Skills for Care, National Skills Academy for Social Care and, of course, the Social Care Institute of Excellence should be routinely be embedded in care practice and those who inspect should also be fully familiar with this in order to ensure inspections are informed. One challenge has always been getting best practice information through to all providers, it is easy for providers to say they don’t have time to look at these things or, in the worst cases, believe they know what they are doing and don’t need any advice. If providers know their inspectors will look at this then they are far more likely to make to time to look at and use this information.

The regulatory framework has increasingly moved toward an outcome based approach, if providers and inspectors do not access the knowledge of what excellent outcomes look like then that system fails.

Undoubtedly, Andrea Sutcliffe has a challenge ahead, one that I am sure she will meet head on, and, ultimately, social care can only benefit by having such an effective leader at the helm.

Health and Social Care Training: The Real Issues

“There is no minimum standard of training for healthcare assistants before they can work unsupervised, an independent report has found” http://www.bbc.co.uk/news/health-23246066

Actually that’s not true!

Back in March Skills for Health and Skills for Care launched the National Minimum Standards for Healthcare and Social Care workers – see http://www.skillsforhealth.org.uk/about-us/news/code-of-conduct-and-national-minimum-training-standards-for-healthcare-support-workers/ . In addition the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 state quite clearly the Health and Social Care providers must ensure employees are “appropriately supported in relation to their responsibilities, to enable them to deliver care and treatment to service users safely and to an appropriate standard, including by receiving appropriate training, professional development, supervision and appraisal” (Regulation 23)

So, the issue is not whether those standards are in place but how those standards are applied, implemented and inspected.

The first area that needs real scrutiny is the induction process.

Imagine that time when you first started in a new job, there is always an element of nervousness as you enter a new environment, have to learn new routines and adapt to working with new people. Now imagine how much information you are likely to retain when you are bombarded with DVD’s or reading material which is supposed to make you competent in the role you are about to undertake!

While we have, in social care, the Common Induction Standards, it has to be remembered these only form a part of the induction process. Induction must be as much about ensuring that new employees learn about the workplace, its routines etc. and how the induction standards apply to the workplace and the individuals receiving care and support there. A tick box approach to the induction standards will not work and there needs to be a greater understanding by managers and leaders in the home of the importance of mentoring new employees to ensure the induction standards are embedded in work practice.

Learning and development must not stop after a successful induction. Professional development is a regulatory requirement and continuous training is important. Even if you have been on endless health and safety courses the chances are going on another will spark something in your mind that you had forgotten or prompt you to think about a bad habit you have got into and encouraged you to change it. Training, aside for giving us new information, can also make us think about how we do things right now, it brings us into ‘conscious competence’, always a good thing to do on occasion.

Supervision and appraisal also serves the same purpose. It helps us question why we do things in certain ways and can make us consider better ways of doing our work. Too often supervision and appraisal are seen as a means to be critical of an employees work but they should be seen as a means of encouraging employees to think about their own role and how they perform it.  

The key issue is to ensure that those responsible to managing and leading staff are sufficiently trained themselves in staff development.

One of the vital areas of training, often overlooked, is the quality of training itself. Certainly I have stopped using training providers because of the negative feedback I had from staff (the usual complaint is ‘they were just reading from a script’ – how can a trainer engage learners when they a focused on reading their lines?) yet how many providers actually get feedback from staff about the quality of training. It is important that providers do this, not only to ensure the quality of training but also to ensure they are not wasting their money!

There are schemes in place which accredit training in social care the principle one being the National Skills Academy for Social Care, and whilst their list is somewhat small at the moment, it would benefit all those who provide social care training to apply for accreditation (here’s the link https://www.nsasocialcare.co.uk/training-providers ).

Given that standards and regulation already exists the obvious question is how are these actually regulated and inspected. If there are issues over training and development why are these not picked up in the inspection process? It can only be speculated that the inspectors themselves are receiving insufficient training into what to look for and what questions to ask about training and development. One of the proposals from the Care Quality Commission’s consultation on inspection is the introduction of ‘specialist’ inspection teams – personally I hope that includes specialist in training and development to ensure standards and regulations are adhered to.

The training and development regulations and standards are there, the issue is how these are applied and inspected, if we can improve this we can improve the general quality of care across the board.

Back to Basics after Winterbourne View: Social Care Training

The Governments final report on Winterbourne View says a lot about the need for staff training but within all of that there is an important phrase that applies right across the social care spectrum and that phrase is “properly trained”.

While there could be some debate about what ‘properly trained’ means it is essential that all care providers reflect on the standard of training that they are providing for their staff. Under the current economic climate it is quite possible that providers are focusing on the cost rather than the quality of training.

Skills for Care and Skills for Health are charged with producing minimum training standards by January but it is unclear as yet whether these will be tick boxes for providers or fundamental changes in the way training must be monitored or delivered yet in either instance care providers should take responsibility for the quality of the training they provide for their staff and this can be done in a number of ways.

Firstly talk to staff. How did they feel about the training, were they engaged with the training or was it just a chore that just had to be done? I know, from personal experience, have conversations like that are useful, once I was informed that a training session was pointless because the trainer just read everything from a book and obviously did not know much about the actual subject. Needless to say that training provider was not used again but without seeking that feedback in the first place the company would probably have continued using the same trainer.

Naturally it would be obviously more useful if care providers could have some assurance about the quality of training providers before they booked them. This is easy for certain courses such as First Aid and Food Hygiene where trainers are accredited by the Chartered Institute of Environmental Health but for other training the route to quality is much less clear.

Yet there is some help, the National Skills Academy for Social Care has started a list of endorsed trainers (available here) and of course word of mouth through local trade associations is a good way to identify recommended trainers. Hopefully the endorsement/registration of trainers in social care will expand to help providers in identifying trainers who can provide appropriately qualified trainers to meet the needs of their particular service.

It is also, perhaps, important that care training providers look at how they can improve their own service by , perhaps, ensuring that the model of care set out in the Winterbourne View report is embedded in any training they deliver and by seeking recognition from the National Skills Academy for Social Care so that providers can trust that they will receive quality training.

Care providers have further responsibility though. Ensuring staff are ‘properly trained’ is not just about what happens in the classroom setting, that training has to be turned into practice and that aspect is the responsibility of the management of the care provider. How aspects such as infection control, medication, mental capacity, adult protection etc. are applied to those the provider cares for can only be done at the point of care delivery and it is essentially vital the staff development activities work hand in hand with formal training.

Unfortunately, when the sector changed from the National Minimum Standards to the Essential Standards of Quality and Safety many of the training standards were lost as the new standards were required to cover hospitals, dentists, ambulance services etc. as well as social care but hopefully the new standards being worked will fill some of this gap.

There can be little doubt that training and the quality of training will be high in the Care Quality Commission inspection agenda and ultimately training provision is the responsibility of the care provider and it is essential that training provided for staff is high quality training that engages and leads to better outcomes for those they provide services for.

You Do Not Get Excellence On The Cheap

At a recent press conference Lord Coe said, "You can never spend too much on elite sport. It will always be the greatest driver of sporting participation and we should be unashamed about that.” He went on to say “Of course, you have to have the right structures in place to deal with that demand. Be under no illusion, you do not get excellence on the cheap”

While we are still in the grip of celebrating sporting achievement those words of Lord Coe could resonate throughout any aspect of society not just sport and particularly in social care.

Excellence is always a driver for success, the concept of being a role model is hardly a new one and while the concept may have become something of cliché it remains a fact that we will always try to emulate our heroes or businesses will endeavour to emulate the success of rivals. Unfortunately, in social care, we do not see the success achieved in supporting people to live active and fruitful lives with the support of family or care workers, we do not outwardly demonstrate the excellence of so many care workers dedicated to enhancing the lives of those who can no longer fully participate in society on their own.

Obviously within the sector we do celebrate excellence, primarily through various awards schemes such as the Skills for Care Accolades, yet those celebrations do not extend outwards to the general population and the only view of social care that achieves mainstream coverage is when things go wrong such as the Winterbourne View case. Yet it is only through showing excellence on a wider scale that we can improve recruitment and retention in the sector and inspire people to work in social care.

The Daily Mirror has stated they have found 61,309 jobs in social care (Care for a Change) and, in the current economic climate it seems incredible that so many jobs are available and, let’s be honest, if that many vacancies exist there are some companies struggling to provide a full level of care and support.

To provide the best possible care services we need the best possible care workers and entice the best we need to demonstrate to the wider public the excellence that already exists to inspire people to see social care as a vocation that is rewarding and intensely satisfying. To achieve that we need investment in the social care workforce, we need to move it from the perception of an underpaid, poorly regulated job to a career that promises recognition and gives a sense of pride in working in a sector that is recognised for its contribution to society and the lives of individuals.

The fragmented nature of social care means that the only way this can be achieved on a national level is by the Government coordinating efforts across all of the Local Authorities and the myriad of care providers. The Government needs to invest in social care to ensure a high level of excellence in care provision that will inspire the public and restore faith in the social care system.

Naturally not everything can always be perfect and rogue careers will always enter the system (not unlike drugs cheats who enter sport) but we need to ensure that excellence is highlighted above all else. To achieve this the Government needs to invest in social care – you do not get excellence on the cheap.

Pass It On: Sharing Social Care Knowledge

If you were to ask a front line care worker if they had heard of Skills for Care, the Social Care Institute of Excellence or the National Skills Academy for Social Care my guess is that the majority will have not.

It is not that they need to have heard of these organisations but it is essential that they hear about the work produced by these organisations and that is where social care leadership is so important. We need to disseminate information, new knowledge and best practice to those who are actually delivering care services to those in need.

Last week, for example, Skills for Care launched a new guide – Supporting Dementia Workers – which sets out 8 Common Core Principles for supporting people with dementia.

Earlier in the month the Social Care Institute of Excellence released a briefing on Preventing loneliness and preventing social isolation among older people and in a month or so the National Skills Academy for Social Care will be launching its Leadership Strategy for Social Care.

All very good work but all pointless if it does not reach the majority of social care providers and social care workers.

The responsibility with obtaining and passing on what is produced by these organisations lays with the care providers and the really good providers will actively seek out what’s new and put it into place but there are many other providers out there who will not.

These are not necessarily bad providers, but could be ones that are just inwardly focused on their business without taking the time to look beyond their own service to what they could do to further improve the lives of the people they provide services for. Other, less good providers, will use every excuse in the book not to look beyond their service - “We don’t have enough time for that sort of thing” etc – or they believe that they know best.

This is not just related to the work of the three organisations mentioned. A few years ago when I delivered a series of training seminars on staff development it was obvious that I was “preaching to the converted” with organisations interested in staff development who were sending their managers to the course, similarly only those outward looking providers send staff to conferences and seminars. Unfortunately it is the “unconverted” that we need to reach to ensure that they understand and deliver the knowledge ad best practice to their workforce.

The challenge, therefore, is to find ways to reach those providers who do not look for new information or believe they do not need that information.

Perhaps one solution is for the Care Quality Commission to enhance their registration of managers to include a requirement that all registered managers must provide evidence of Continuing Professional Development annually in order to maintain their registered status. This is a standard requirement (albeit not annually) for most other registered  professionals and it would ensure that all Registered Managers undertake some form of external training that would extend their wider knowledge of new developments in social care.

Additionally those commissioning services could take a more proactive approach to ensuring best practice is disseminated. Where local authorities offer conferences etc for providers we come against the same problems of only the good providers sending staff to them so commissioners need to be more active in ensuring that those they pay money to are fully up to date with best practice and new knowledge.

There are many sources of information, knowledge and good practice in social care but we need to make certain that all of reaches those who are actually delivering front line care services if we want those in need of services to benefit from it.

N.B. For Tweeters:   National Skills Academy for Social Care - @NSASocialcare

                                    Skills for Care - @SkillsforCare

                                    Social Care Institute of Excellence - @SCIE_Socialcare

Let's Get Social Care Out of the Darkened Corner

The Health & Social Care Act 2008 received Royal Assent on 22^nd July 2008 but the bulk of the provisions relating to social care where not put in force until 1^st October 2010. So, in essence, there was a two year gap between the final stage of the Parliament and the implementation of the Act. Of course, this is just the end of the process, a bill has to travel through the parliamentary process. For example, the controversial Health & Social Care Act 2012 had its first reading in Parliament on 19 Jan 2011 and received Royal Assent on 27 Mar 2012, probably an extreme example but it highlights the length the process can take.

What’s the point of that little tour of the Parliamentary process?

Simply speaking, the current Government has three years, at the most, left and unless they take action soon on social care there will not be any changes to the current system while this Government is in power, if they do, eventually, legislate it will be left to the next Government, whoever they are, to implement any changes made. And, more importantly, it could be close to three years to see any substantive change in the social care system (always assuming the Government put any substantive changes in a bill!).

To most of us in the sector such prevarication on social care is not unusual and not just limited to the Government in power at present. I won’t repeat the gist of my previous blog (Politicians Seem Clueless About Social Care) but suggest what we need is a radical approach to reforming social care at the very top.

When Ivan Lewis was named care minister in 2006 he promised a radical review of social care, unfortunately that never happened and the first announcement of a consultation on social care came only once Alan Johnson took over the role of Health Secretary from Patricia Hewitt a year later. This suggests that any real action on social care is decided by the senior minister who sits on the cabinet.

Obviously the Health Minister is generally more concerned about Health Care rather than Social Care as evidenced by this Governments pushing through the 2012 Act despite opposition from many health professional organisations. Social Care seems to occupy a tiny corner within the Department of Health thinking.

But why does social care sit in the Department of Health?

Social Care is not a minor area of public policy to be handily attached to what appears to be the most appropriate Ministry.

The number of people receiving local authority funded services in 2010/2011 was 1.6 million and this excludes people who pay for their own care and people deemed by social services as not having sufficient need level to qualify for support and who are cared for by unpaid family members etc., so true figure of those who may need social care services is considerably higher.

Skills for Care estimate that the social care workforce also numbers 1.6 million. So, at a minimum, 3.2 million people are involved in social care services. Add to this the fact that Skills for Care also “work closely with the 40,600 organisations that offer social care people who use services, carers and with other key stakeholders” and it is hard to see why social care does not get much more attention than say the Department of Culture, Media & Sport which has a Cabinet Minister in Charge.

It is also important to remember that social care is not just about health, although that may play a significant part in end of life care etc. the role of social care is to support and care for individuals in their day to day living and health remains the responsibility of health professionals. The public often only connect social care with elderly care but it goes beyond this and beyond the remit of health.

For adults below the age of 65 who need social care services much of the focus is on appropriate housing, employment opportunities and living independently. The latter of which is also a focus of social care for the elderly. Social care is about maintaining links with society and maintaining social well-being in addition to health well-being.

We need action on social care and we need political consensus rather than political paralysis. Let’s start by achieving consensus that social care should not sit in a darkened corner of the Department of Health and it deserves its own Ministry with its own Minister who sits on the Cabinet and has the opportunity to bring forward legislation but more importantly to show that Westminster is truly serious about working for the millions in the country who receive or are involved in delivering, social care services.